As the last couple of speakers have spoken about there are a number of mechanisms that influence the actual pain beyond actually the disease itself. What nutrition can often do is support relaxing or modulating those mechanisms similar to some of the drugs actually, using similar pathways but today we are going to talk about how to do those with food.

Some of these mechanisms are the inflammation, the immune system that we just heard about, hormonal imbalances such as estrogen dominance, and also digestive dysfunction and pain. A lot of people have overlapping not just interstitial cystitis but also irritable bowel syndrome and constipation. If we come from a nutrition approach and resolve or optimize really the digestive function, often that can help with the symptoms.

We look at collaborating with these other therapies, with the surgery, with physical therapy, with medical therapies in some cases. We are looking at dealing with all three of these different mechanisms. They interact with each other so if you have a physical stressor or even an emotional stressor inflammatory types of foods can be a stressor then they are going to interact with the endocrine system, the digestive system, the microbiome, which is a huge topic that I do not have time to get into today, which also helps with optimal digestive functioning and modulating the immune system and the nervous system. The immune system especially these inflammatory mediators called cytokines and also the prostaglandins that Dr. DeGregoris talked about before.

Our goal here is to reduce the sensitivity of the nervous system by calming that inflammatory response and these other mechanisms. Also sometimes inflammation can directly relate to pain so you will have reduction of pain directly from reducing general systemic inflammation which you can do with your diet.

Some studies have looked at the inflammation in endometriosis. In the peritoneal cavity in the abdomen they do find that there are elevated inflammatory mediators. One way nutritionally to reduce some of the inflammation is to use antioxidants. One example of this is in mouse models of endometriosis high doses of vitamin C, which is one of the antioxidants significantly reduced the volumes and weights of endometriotic cysts. These studies have not been done in humans but I do use similar strategies with my clients to increase the antioxidant load to impact inflammation. Similarly, another food or supplement, depending on how you get it, is from wild fish in fairly high amounts of about 12 to 16 ounces per week, or by taking fish oil supplements. There was also a study looking at dysmenorrhea. This was done in humans and was not a great study. They did not actually target individualized omega-3 fatty acid needs but this is another one of those food or supplement based things that you can use to reduce inflammation. I think this study would have been even more effective had they looked at each individual woman’s need for omega-3 fatty acids in comparison to her level of omega-6 fatty acids which tend to be more pro-inflammatory, most of them.

The way that a lot of these foods and supplements work is they inhibit part of the inflammatory response called NFkB. This is not an exhaustive list but some of the things that you can include in your diet to inhibit NFkB include things like circumin which are found in Turmeric or green tea. Gamma Linolenic Acid, which is actually primarily found in breast milk but we also get it in adulthood in green leafy vegetables, nuts, supplements like evening primrose oil, borage oil and black current seed oil. As I mentioned before EPA, which is one of the omega-3 fatty acids, which is found in fish and fish oil specifically the kind of deep water, wild, fatty fish, so things like wild salmon. Also rosemary, actually spices, culinary spices are very high in a lot of these anti-inflammatory mediators. Just adding things like oregano, rosemary, cinnamon to your meals makes them more delicious because sometimes when clients come to work with me and we are shifting their diet in such a way that might feel restrictive at first, which is not every my intention, we try to make it enjoyable, but adding spices really helps. And then there is resveratrol. Having it in red wine generally you cannot get it in high enough doses because there is an alcohol issue but blueberries and grapes are other good sources.

Additional supplements – you want to make sure your vitamin D levels are optimal. The blood test that measure 25-hydroxy vitamin D in the blood should be between 70 and 90 optimally, particularly if you are dealing with an inflammatory issue. CoQ10 is another supplement that may be an issue that can be low on blood tests and can be supplemented. Grape seed extract is a good supplement for reducing inflammation. Indole-3-carbinol is actually a metabolite of cruciferous vegetables, so another way to get this is eating fairly large amounts, something like two cups a day of broccoli or other cruciferous vegetables, or you can get it in supplement form. The other benefit to this particular supplement is that it helps to more optimally metabolize estrogen, so we are reducing the estrogen overload and that is one way to get there, there are a couple of other supplements that do that as well. Selenium and zinc are also really important for inhibiting NFkB. Zinc is also really important for optimizing digestive function. It keeps the lining of the intestines healthier.

I have given you a number of different little pieces of data so where would you begin if you wanted to just overhaul your diet to create an environment in your body that is less inflammatory, that calms the sensitivity of the nervous system and begins to optimize your digestive function. You want to start with clean proteins. Most of my clients are omnivore so we go with organic grass-fed meats and wild caught fishes. But you can actually and we are about to publish a study, this patient did not have endometriosis as a case report but she have vulvodynia and irritable bowel syndrome that we were able to do a vegan plan that also worked. And kind of protein that is very clean, often it can be beneficial to use some animal proteins for absorption but a lot of that really depends on your genetics and your preferences, either one can work. Healthy fats from fatty wild caught fish, avocado, olive oil, raw or soaked and sprouted nuts and seeds, lots of vegetables. I will show you some examples of how we eat the rainbow in a moment. Some fruits, but stick with the ones that are lower in sugar, so not the tropical fruits but the ones like berries and green apples. Grains are tricky. Some women really tolerate healthy, properly soaked and prepared whole grains. Generally women with endometriosis do not tolerate gluten well but some can tolerate some of the other grains, other cannot. We do individual kind of elimination diets to see which works better.

When you are thinking about daily kind of anti-inflammatory foods the best way to get this is through lots of vegetables of all different colors. You want to see if you can hit every color of the rainbow. If you have children see if you can get them to eat a few in each category each day and just think of that as a wide color because you will get different things from each of those colors.

Also we look at reducing stress and that is not just emotional stress but also physiologic stress. If your body is under pressure of lots of foods that increase inflammation that can also affect hormone levels negatively. We want to avoid foods like anything processed, any sugar or artificial sweeteners, transfats, processed grains like flours that are found in pastas and breads and baked goods. Excess estrogen can promote endometriosis so we want eat foods that help the liver metabolize estrogen. I talked about one of the metabolites a moment ago. Also, just generally eating more cruciferous vegetables and then their components we sometimes use as supplements.

The liver which helps to metabolize estrogen thrives on vitamins, minerals, antioxidants and amino acids. This is a really busy slide but what I want you to get from this is that you need all of these vitamins, minerals, lots of amino acids, which is why you need plenty of protein to support estrogen metabolism. We also want to avoid environmental estrogen chemicals so we use things like glass food storage containers, glass or stainless steel water bottles, eating organic whenever possible and looking at the environmental working groups, Clean 15 and Dirty Dozen will show you which fruits and vegetables have naturally lower pesticide levels and drinking filtered water. These kinds of things help reduce estrogen exposures.

Then finally, as we talked about very often, endometriosis overlays with irritable bowel syndrome. We want to think about starting with the mouth and even the environment in which you are eating optimizing the function of your digestion. Are you eating in a calm environment, are you chewing your food. Evidence-based number of times you need to chew each bite is between 20 and 40 per bite and making sure you have enough stomach acid and that is something you can work with your nutritionist about. Digestive enzymes are also important and difficult to make for people who have chronic pain or chronic fatigue because they take a lot of energy to produce. Also you want a healthy intestinal lining, healthy bacterial environment in the colon and plenty of hydration. We want to make sure our gut motility is optimized and visceral physical therapy that Sallie just talked about can really help with that as well.

What I want you to come away with is that this is all connected and how you eat and how you think and how even the environment in which you eat all helps to support optimal functioning of the brain’s response to pain of the digestive system and of the inflammatory messengers that speak between these different systems. Thank you.

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